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Karen Levy, PhD, MPH
October 2013
Salúd Ambiental en Chile: Orientación para Futuras
Investigaciones
Planning for a GeoHealth Hub in Chile
Agua Potable y Enfermedades
Gastrointestinales en Esmeraldas,
Ecuador y Atlanta, GA
•Overview of contamination between
source and point of use
•Case Study from Esmeraldas, Ecuador
•Case Study from Atlanta, GA
Agua Potable y Enfermedades
Gastrointestinales en Esmeraldas,
Ecuador y Atlanta, GA
Storing water
Deterioration of
water quality
Higher water quality observed at the
source than at the point of use
Wright et al. 2004. Tropical Medicine & International Health 9(1): 106-117
•Case Study from Esmeraldas, Ecuador
Study Region
bathing
washing
1°	
  water	
  source	
  is	
  
surface	
  water
collec.ng	
  water
Xt=0
Point
of Use
xPOU, t=1, xPOU, t=2, …xPOU, t=n
Source
Controlled
Env’t
xcontrol, t=1, xcontrol, t=2, …xcontrol, t=n
Agua almacenado en la casa
Muestras de agua de la fuente
Recipientes Controles
testing for e.coli & enterococci in the field
    N   Enterococci
CFU/100mL
  E.coli
CFU/100mL
Source 59 227.9 227.1
(139.5 – 372.4) (144.6-356.9)
Household 105 103.7 113.4
(70.7-152.1) (80.8-159.0)
Control 105 80.8 83.8
(54.3-120.1) (57.8-121.5)
Contamination:
Source > Point of Use
Contaminación Observada
Paired log differences:
Natural attenuation = Source – Control
In-home attenuation = Source – Household
In-home recontamination = Household - Control
Enterococci E.coli
(GEE regressions adjust for clustering by paired household samples,
and to account for autocorrelation between sampling days) n=105
Findings
Reductions of indicator organisms between source and POU…
…followed by recontamination in ~50% of households
Levy et al. 2008. Environmental Health Perspectives
116(11): 1533-1540.
This suggests the need to consider both initial water
quality conditions and recontamination
•Case Study from Atlanta, GA
• Does water degradation in the distribution
system contribute to sporadic GI illness?
Source: Besner et al. 2011 Water Research 45: 961-979
Source: Besner et al. 2011 Water Research 45: 961-979
ER visits
Gastrointestinal Disease Data
• 41 hospitals in Metro Atlanta
• 4.4 million ED records
• 254,760 GI illness records
(based on ICD-9 codes)
• Non-injury visits = comparison
group
• Address + zip-code data for
majority of records
Water Utility Data
• Hydraulic Models
• Utility Coverage Areas
• Water Residence Time from plant to node
(estimated through simulations of water
flow through the distribution system)
Source: Besner et al. 2011 Water Research 45: 961-979
Water
Residence
Time
ER visits
Utility 1 Utility 2
WRT: short 6.8 /intermediate 22.0 / long 47.4 hrs
WRT: short 10.1 / intermediate 33.4 / long 74.4 hrs
WRT: short 5.9 / intermediate 18.5 / long 60.4 hrs
ControlVariables
(Census Data & ED records)
• Age
• Season
• Year
• Hospital
• Distance from zip code centroid to hospital
• Zip code median income
• Zip code percent minority
• Medicaid payment status
• Age*Medicaid
• Age*Distance to hospital
• Medicaid*Distance to hospital
OddsRatio
Based onTinker et al. 2009. JWH 7(2): 332-343
.85
.85
.85.95
.95
.951.05
1.05
1.051.15
1.15
1.150
0
0.5
.5
.51
1
11.5
1.5
1.52
2
20
0
0.5
.5
.51
1
11.5
1.5
1.52
2
2Utility 1
Utility 1
Utility 1Utility 2
Utility 2
Utility 2Zipcode WRT, All addresses, 28 hospitals
Zipcode WRT, All addresses, 28 hospitals
Zipcode WRT, All addresses, 28 hospitalscomparison_no
comparison_no
comparison_no
Water Residence Time
Short Intermediate Long Short Intermediate Long
OR = 1.05
(1.00-1.09)
OR = 1.05
(1.02-1.08)
Conclusions:
• People living in zip codes receiving water
with the longest residence time in the
distribution system may be at moderately
increased risk for GI illness
Follow-up Study to Evaluate
Microbial Water Quality in the
Distribution System
• Water Residence Time
• Main Breaks
• Pressure Fluctuations
Monitoring
Locations
Automated Monitoring and
Sampling (AMS) Device
Ultrafiltración para
Muestras de GranVolumen
Recycle
Pump
Sample
reservoir100 L
Ultrafilter
Air vent
Retentate
reservoir
Q Permeate (waste)
Flow
Flow
Restrictor
Dead-end
Flow meter
1L
2,900 mL/min
1
,
2
1,100 mL/min
3-way valve
Water
Sample!
Filtered Water!
(aka “filtrate” or “permeate”)!
(UF Membrane)!
Microbes!
Suspended solids!
Colloidal matter!
Large dissolved molecules!
Hollow Fiber Ultrafiltration Schematic
Division of Foodborne,Waterborne and
Environmental Diseases at the CDC in
Atlanta with Dr.Vincent Hill!
Microbiological Analysis
Membrane
Filtration
~400 ml
Concentrate + Back flush
PEG
0.1 mL 1 mL 10 mL
E. coli; Total coliforms; C. perfringens;
HPC; P. aeruginosa; A. hydrophila
60 to 100 mL
Actual volume filtered for each
Standard Methods for the Examination of Water and Wastewater; 20th Edition, 1999 American Public Health Association Publications
Sample Collection
AMS (90L) or Grab sample (2L)
Ultrafiltration
(AMS, 90L)
100 mL
10^3 10^4 10^5
25 ml actual volume pour plate each
Male-specific (MS2) and Somatic
Coliphage
Dr. Nick Ashbolt lab
Mycobacterium avium
complex (MAC),
Legionella +amoebae,
Cryptosporidium
1 2 3 4 5 6
0
0. 5
1. 0
1. 5
2. 0
E
.
c
o
l
i
C
F
U
/
1
0
0
m
l
Si t e
Acknowledgements
• Funding: EPA-STAR grant #R834250
(PIs Christine Moe & Paige Tolbert)
• Co-Authors: Mitch Klein, Stefanie Sarnat, Sarah
Tinker, Samina Panwhar, Alexandra Huttinger,
Jim Uber, Paige Tolbert, Christine Moe
• Other:Water Utility staff, Hospital staff
R834250
The content of this presentation is solely the responsibility of the grantee
and does not necessarily represent the official views of the US EPA
Co-­‐Authors:
• Kara	
  Nelson
• Alan	
  Hubbard	
  
• Joe	
  Eisenberg
Field	
  Assistance:
• Sarah	
  Bates
• Sangam	
  Tiwari
• Laura	
  McLaughlin
• Karina	
  Ponce
• Patricio	
  Bueno
• William	
  Cevallos
• Geovanny	
  Hurtado
• Maritza	
  Renteria
• Deni	
  Tenorio
• Jairo	
  Ayovi
• Mirta	
  Campaz
• Melecio	
  Quintero
• Owen	
  Solberg
• Khalid	
  Kadir
ACKNOWLEDGEMENTS
Funding:
• NIAID	
  Grant	
  #RO1AI050038	
  
• UCOP	
  Pacific	
  Rim	
  Research	
  
Program
gracias.
Good
San
Good WQ
Bad WQ
Bad
San
Highest potential for
recontamination
High potential for
recontamination
Intermediate potential
for recontamination
Lowest potential for
recontamination
improve water
storage &
sanitation
improve water
storage
integrated
approach
improve wq +
water storage
Other Water Sources
rainwater
harvesting
piped surface
water
private
wells

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K levy chile_geo_health_2013

  • 1. Karen Levy, PhD, MPH October 2013 Salúd Ambiental en Chile: Orientación para Futuras Investigaciones Planning for a GeoHealth Hub in Chile Agua Potable y Enfermedades Gastrointestinales en Esmeraldas, Ecuador y Atlanta, GA
  • 2. •Overview of contamination between source and point of use •Case Study from Esmeraldas, Ecuador •Case Study from Atlanta, GA Agua Potable y Enfermedades Gastrointestinales en Esmeraldas, Ecuador y Atlanta, GA
  • 4. Higher water quality observed at the source than at the point of use Wright et al. 2004. Tropical Medicine & International Health 9(1): 106-117
  • 5. •Case Study from Esmeraldas, Ecuador
  • 9. 1°  water  source  is   surface  water collec.ng  water
  • 10. Xt=0 Point of Use xPOU, t=1, xPOU, t=2, …xPOU, t=n Source Controlled Env’t xcontrol, t=1, xcontrol, t=2, …xcontrol, t=n
  • 12. Muestras de agua de la fuente
  • 14. testing for e.coli & enterococci in the field
  • 15.     N   Enterococci CFU/100mL   E.coli CFU/100mL Source 59 227.9 227.1 (139.5 – 372.4) (144.6-356.9) Household 105 103.7 113.4 (70.7-152.1) (80.8-159.0) Control 105 80.8 83.8 (54.3-120.1) (57.8-121.5) Contamination: Source > Point of Use Contaminación Observada
  • 16. Paired log differences: Natural attenuation = Source – Control In-home attenuation = Source – Household In-home recontamination = Household - Control Enterococci E.coli (GEE regressions adjust for clustering by paired household samples, and to account for autocorrelation between sampling days) n=105
  • 17. Findings Reductions of indicator organisms between source and POU… …followed by recontamination in ~50% of households Levy et al. 2008. Environmental Health Perspectives 116(11): 1533-1540. This suggests the need to consider both initial water quality conditions and recontamination
  • 18. •Case Study from Atlanta, GA
  • 19.
  • 20.
  • 21. • Does water degradation in the distribution system contribute to sporadic GI illness?
  • 22. Source: Besner et al. 2011 Water Research 45: 961-979
  • 23. Source: Besner et al. 2011 Water Research 45: 961-979 ER visits
  • 24. Gastrointestinal Disease Data • 41 hospitals in Metro Atlanta • 4.4 million ED records • 254,760 GI illness records (based on ICD-9 codes) • Non-injury visits = comparison group • Address + zip-code data for majority of records
  • 25. Water Utility Data • Hydraulic Models • Utility Coverage Areas • Water Residence Time from plant to node (estimated through simulations of water flow through the distribution system)
  • 26. Source: Besner et al. 2011 Water Research 45: 961-979 Water Residence Time ER visits
  • 27. Utility 1 Utility 2 WRT: short 6.8 /intermediate 22.0 / long 47.4 hrs WRT: short 10.1 / intermediate 33.4 / long 74.4 hrs WRT: short 5.9 / intermediate 18.5 / long 60.4 hrs
  • 28. ControlVariables (Census Data & ED records) • Age • Season • Year • Hospital • Distance from zip code centroid to hospital • Zip code median income • Zip code percent minority • Medicaid payment status • Age*Medicaid • Age*Distance to hospital • Medicaid*Distance to hospital
  • 29. OddsRatio Based onTinker et al. 2009. JWH 7(2): 332-343 .85 .85 .85.95 .95 .951.05 1.05 1.051.15 1.15 1.150 0 0.5 .5 .51 1 11.5 1.5 1.52 2 20 0 0.5 .5 .51 1 11.5 1.5 1.52 2 2Utility 1 Utility 1 Utility 1Utility 2 Utility 2 Utility 2Zipcode WRT, All addresses, 28 hospitals Zipcode WRT, All addresses, 28 hospitals Zipcode WRT, All addresses, 28 hospitalscomparison_no comparison_no comparison_no Water Residence Time Short Intermediate Long Short Intermediate Long OR = 1.05 (1.00-1.09) OR = 1.05 (1.02-1.08)
  • 30. Conclusions: • People living in zip codes receiving water with the longest residence time in the distribution system may be at moderately increased risk for GI illness
  • 31. Follow-up Study to Evaluate Microbial Water Quality in the Distribution System • Water Residence Time • Main Breaks • Pressure Fluctuations
  • 32.
  • 33.
  • 34.
  • 37. Ultrafiltración para Muestras de GranVolumen Recycle Pump Sample reservoir100 L Ultrafilter Air vent Retentate reservoir Q Permeate (waste) Flow Flow Restrictor Dead-end Flow meter 1L 2,900 mL/min 1 , 2 1,100 mL/min 3-way valve
  • 38. Water Sample! Filtered Water! (aka “filtrate” or “permeate”)! (UF Membrane)! Microbes! Suspended solids! Colloidal matter! Large dissolved molecules! Hollow Fiber Ultrafiltration Schematic Division of Foodborne,Waterborne and Environmental Diseases at the CDC in Atlanta with Dr.Vincent Hill!
  • 39. Microbiological Analysis Membrane Filtration ~400 ml Concentrate + Back flush PEG 0.1 mL 1 mL 10 mL E. coli; Total coliforms; C. perfringens; HPC; P. aeruginosa; A. hydrophila 60 to 100 mL Actual volume filtered for each Standard Methods for the Examination of Water and Wastewater; 20th Edition, 1999 American Public Health Association Publications Sample Collection AMS (90L) or Grab sample (2L) Ultrafiltration (AMS, 90L) 100 mL 10^3 10^4 10^5 25 ml actual volume pour plate each Male-specific (MS2) and Somatic Coliphage Dr. Nick Ashbolt lab Mycobacterium avium complex (MAC), Legionella +amoebae, Cryptosporidium
  • 40.
  • 41. 1 2 3 4 5 6 0 0. 5 1. 0 1. 5 2. 0 E . c o l i C F U / 1 0 0 m l Si t e
  • 42. Acknowledgements • Funding: EPA-STAR grant #R834250 (PIs Christine Moe & Paige Tolbert) • Co-Authors: Mitch Klein, Stefanie Sarnat, Sarah Tinker, Samina Panwhar, Alexandra Huttinger, Jim Uber, Paige Tolbert, Christine Moe • Other:Water Utility staff, Hospital staff R834250 The content of this presentation is solely the responsibility of the grantee and does not necessarily represent the official views of the US EPA
  • 43. Co-­‐Authors: • Kara  Nelson • Alan  Hubbard   • Joe  Eisenberg Field  Assistance: • Sarah  Bates • Sangam  Tiwari • Laura  McLaughlin • Karina  Ponce • Patricio  Bueno • William  Cevallos • Geovanny  Hurtado • Maritza  Renteria • Deni  Tenorio • Jairo  Ayovi • Mirta  Campaz • Melecio  Quintero • Owen  Solberg • Khalid  Kadir ACKNOWLEDGEMENTS Funding: • NIAID  Grant  #RO1AI050038   • UCOP  Pacific  Rim  Research   Program
  • 45. Good San Good WQ Bad WQ Bad San Highest potential for recontamination High potential for recontamination Intermediate potential for recontamination Lowest potential for recontamination improve water storage & sanitation improve water storage integrated approach improve wq + water storage
  • 46. Other Water Sources rainwater harvesting piped surface water private wells